Oct. 17, 2017
Prime Therapeutics’ Studies Examine Rheumatoid Arthritis Therapies and Total Cost
Prescribing in accordance with guidelines can reduce total cost of care.
ST. PAUL, Minn. – Two new studies by pharmacy benefit manager Prime Therapeutics LLC (Prime) show commercially insured members with rheumatoid arthritis (RA) had 3.5 times higher total cost of care than members without RA. But optimizing conventional disease modifying antirheumatic drug (DMARD) therapy and giving conventional DMARDs an adequate trial in accordance with national guidelines – before starting high-cost ‘biologic’ specialty drugs – has the potential to reduce RA costs. As shown in Prime’s research, guidelines aren’t being followed often enough. The studies will be presented at the upcoming Academy of Managed Care Pharmacy’s (AMCP) Nexus 2017 conference Oct. 16 to 19.
Up to 23.5 million Americans suffer from autoimmune diseases, which include rheumatoid arthritis – and according to the National Institutes of Health, the prevalence is rising.1 Within Prime’s commercial book of business in the first half of 2017, biologic anti-inflammatory treatments led spending among specialty categories, comprising more than 13 percent of total expenditures.2
For both studies, Prime researchers evaluated continuously enrolled commercially insured members from 2013 to 2016 who were younger than 65 years old. Of 3.5 million members who met the study’s criteria, 26,098 (0.7 percent) had RA, while the remaining members did not have claims indicating an RA diagnosis (matched non-RA).
In the first study, the mean per patient per year (PPPY) total cost of care for individuals with RA was $27,993. This cost was 3.5 times higher than the $8,149 PPPY total cost of care for a matched non-RA comparison. Of the $19,844 in excess costs for members with RA, prescription drug claims for biologic DMARDs accounted for 61.3 percent of claims expenses, while conventional DMARDs made up 2.1 percent of claims expenses. Individuals with RA who use conventional DMARDs, that are mostly generic and cost less than $1,000 per year, had a $15,668 PPPY total cost of care, which was only 1.8 times higher than the matched non-RA comparison. Biologic DMARD users had a $51,911 PPPY total cost of care, which was 6.4 times higher than the matched non-RA comparison group, and biologic drug therapy accounted for more than $35,000 of the $51,991 PPPY.
“When autoimmune drugs account for 1 of every 10 dollars spent on all drugs, you have to question what additional value biologic DMARDs are bringing over generic conventional DMARDs when the biologics are 35 times more expensive,” said Kevin Bowen, M.D., principal health outcomes researcher at Prime. “There are more cost-effective alternatives that are being ignored. Conventional DMARDs are a few dollars per day compared to expensive specialty drugs at $100 per day, so conventional DMARD therapy should be optimized to bring down the total cost of care in this category.”
The second study demonstrated an opportunity for utilization management strategies to encourage compliance with American College of Rheumatology guideline recommendations.
Six percent of members studied started new treatment with a biologic DMARD with no conventional DMARD claim in the prior 12 months. This is inconsistent with RA guidelines. Eleven percent of members started on a conventional DMARD escalated to a biologic DMARD within 12 weeks of starting their conventional DMARD, which is an inadequate trial of this therapy according to RA guidelines. Twenty-six percent of members initiated biologic DMARD therapy less than 24 weeks after their first claim for conventional DMARD therapy, which would appear to be insufficient time for even one adjustment of the conventional DMARD regimen. Lastly, less than 5 percent of individuals newly initiating a biologic DMARD had tried triple conventional DMARD therapy, a regimen that has been proven to be substantially more cost effective than a biologic DMARD for patients who still have active disease after treatment with a single conventional DMARD such as methotrexate.3
“RA guidelines supporting use of conventional DMARDs before biologics have been in place for a decade, so it’s concerning that when we reviewed our integrated data, 6 percent of patients skipped the conventional DMARD step altogether,” said Bowen. “Additionally, this research found suboptimal triple conventional DMARD therapy use and high biologic DMARD discontinuation rates in RA patients, indicating waste, which continues to add cost to the health care system.”
To improve the basic management of this drug class and effectively optimize conventional DMARD use, utilization management tools like step therapy can be deployed to help members initiate a conventional DMARD before a biologic therapy is initiated. Through the analysis of pharmacy and medical data, Prime’s GuidedHealth® program provides actionable clinical intelligence to doctors, members and plans. These insights can result in improved care, safer medicine use, better outcomes and lower overall cost of care.
2. Prime Therapeutics. Focus on Trend: Commercial. Fall 2017.
3. Bansback N, et al. Triple Therapy Versus Biologic Therapy for Active Rheumatoid Arthritis. Annals of Internal Medicine, 2017; DOI: 10.7326/M16-0713
About Prime Therapeutics
Prime Therapeutics LLC (Prime) helps people get the medicine they need to feel better and live well. Prime manages pharmacy benefits for health plans, employers, and government programs including Medicare and Medicaid. The company processes claims and offers clinical services for people with complex medical conditions. Prime serves more than 20 million people. It is collectively owned by 18 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans.
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